Failure to Reconcile and Document Controlled Substance Counts per Policy
Penalty
Summary
The facility failed to ensure that inventories of Schedule II, IV, and V controlled substance medications were reconciled by at least two qualified staff members each shift, as required by facility policy. Multiple days were identified where there was no documentation of shift-to-shift narcotic medication counts, no nurse signatures on narcotic count sheets, and no total card counts for the A-hall medication cart. This lack of documentation occurred across all three daily shifts on several dates, and included the absence of required log sheets for certain periods. The facility's policy required two staff members to count and sign off on all controlled substances at the start and end of each shift, but this was not consistently done. Review of individual resident narcotic count sheets confirmed that various controlled substances, including Ativan, morphine sulfate, hydrocodone/acetaminophen, Roxanol, Lyrica, tramadol, and oxycodone, were stored in the narcotic lock box for ten residents. Despite the presence of these medications, the required documentation and reconciliation procedures were not followed. Observations and record reviews showed that for several days, there were no signatures or documentation to verify that the counts were completed as per policy. Interviews with nursing staff and the Director of Nursing revealed a lack of adherence to the established procedures for narcotic counts. Staff acknowledged that two nurses were supposed to count and sign for the narcotics at each shift change, but this was not consistently practiced. The Director of Nursing and the Administrator both stated that they expected staff to complete and document the narcotic counts at every shift change, but were unaware of the missing documentation until it was brought to their attention during the survey.